Wiki OB Global Billing - insurance companies

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tkeeton7885

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I have a patient who has changed insurance companies during her pregnancy. She became a new OB patient on 10/25/07 and has had 9 visits during her coverage under 'Plan A'. Effective 4/1/08 she will be covered under 'Plan B.' Her expected date of delivery is May 3,2008. At this point, I am assuming she will be seen for at least 4 visits under 'Plan B.' I am not sure how to bill the visits to 'Plan A' for her 9 antepartum visits. Should I bill CPT 59426 to 'Plan A' and the delivery code 59400-52 to 'Plan B'? (I am appending modifier -52 to 'Plan B' insurance since she will be seen for less than 13 antepartum visits). Naturally, these claims will not be filed until after her delivery. Please advise and thanks in advance!
 
You will go ahead and bill the first insurance now for the number of visits, in this case being 9 it would be 59426. After her delivery you will need to bill the antepartum separate from the delivery using either 59425 (4-6) or 59426 (7+) or if under 3 antepartum visits each will need to be billed individually. Then you bill for the delivery with post partum only. You will not use a global delivery code with -52. Hope this helps.
 
I concur with the billing before she delivers - but you should bill plan B for a total ob care because this is not part of the same Payer but a completely new service.
 
You should bill ins co A for the 9 visits 59426--once the pt delivers you would bill ins co B for the amount of prenatals (59425 for 4-6 or 59426 for 7 + visits). The delivery would be billed as 59410 vaginal delivery plus postpartum or if c/section you would bill 59515 for delivery plus postpartum. Hope this answers your question.
 
Another question about this scenario

In billing antepartum care only,, the 59426 or 59425,, how do you go about choosing which visit to use as the date for your service? I would think the first visit, but then when you bill it you run into timely filing and what not,, so should it be the last date of service instead that you use for billing the antepartum charges?
 
anteparteum

I use the last visit date during the effective time of the insurance with plan A... Some insurance however do want to know the exact dates of the visits so sometimes these have to be noted and the claim sent hardcopy with those dates noted. Hope this helps. Lucy
 
I am likewise wondering with an insurance coverage change.... We have a patient who has had his TKA explanted and an antibiotic cement spacer implanted while under coverage A. We are now removing the spacer and implanting TK components under coverage B. Do I need to use modifier for staged in the global period to company B? or not since they never processed the previous claim(s).Thank you.
 
StuC2018 said:
I am likewise wondering with an insurance coverage change.... We have a patient who has had his TKA explanted and an antibiotic cement spacer implanted while under coverage A. We are now removing the spacer and implanting TK components under coverage B. Do I need to use modifier for staged in the global period to company B? or not since they never processed the previous claim(s).Thank you.
Click to expand...
The OB scenarios can be different (which this really old thread was related to). However, if you append a 58 to the TKA claim for the explant spacer/implant TKA to the new payer it may be rejected or denied because they have no prior claim with a global. 58 restarts the global period and shouldn't be a reduction in payment so you should leave it off, in my opinion. I have seen it where it just goes through but it can depend on how well the clearinghouse edits and/or payer edits are.
If you were appending a 78 for complication, that could get sticky because if you appended that to the second case to the original payer with the global, it usually comes with payment reduction. So for compliations (78) I would probably append it. Although, if they have no global to bump up against, it still may not work right. You would just have to keep an eye on the claim(s).

In another example, let's say you were billed and paid by Ins. A for a 27447, the patient's insurance changes, and someone decides to bill the post-op follow ups as E/M office visits to Ins. B and you get paid. That's wrong because you already got paid for the global by A.
 
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